UMass Memorial scrambles to fix water problem

Saturday

Jan 12, 2013 at 6:00 AMJan 12, 2013 at 8:45 AM

By Thomas Caywood TELEGRAM & GAZETTE STAFF

UMass Memorial Medical Center is scrambling to rip out and replace the sterilization system at its Memorial Campus on Belmont Street after operating room staff found black flecks on supposedly sterile surgical equipment a number of times recently.

“We became aware of the presence of these particles in an occasional surgical pack about 10 days ago, and then began to see them with increasing frequency,” said Dr. Stephen Tosi, the hospital chief medical officer. “If the particles were observed, the surgical pack was immediately removed from use, and replaced with sterile, particle-free instruments.”

Dr. Tosi said the particles, which he described as resembling ground pepper, have been tested and found to be neither toxic nor infectious. Surgical instruments contaminated with the black flecks were not used on patients, he said.

The source of the flecks has been traced to the machines that sterilize surgical instruments and to related water supply lines, forcing the hospital to cancel or postpone numerous scheduled surgeries until the entire system can be replaced, a process that could take up to three weeks, according to hospital officials and internal communications obtained by the Telegram & Gazette.

The contaminants are thought to have entered the hospital's water system after a major city water main break in mid-November that forced water service to be shut off to the entire city overnight. Sediment often settles harmlessly at the bottom of municipal water mains over years, but it can be swept up into the flow of water gushing through the pipes again after a shutdown.

State hospital regulators are monitoring the hospital's efforts to replace the complex sterilization system and, in the meantime, perform some surgeries at the Memorial Campus with instruments sterilized at UMass Memorial's other area hospitals.

“The Department of Public Health has been notified of contamination identified in the water system supplying UMass Memorial Medical Center. The hospital has taken necessary precautions and is working closely with department staff to ensure patient safety. The department will monitor this situation until it is resolved,” DPH spokeswoman Anne Roach said.

Memorial Campus will have to reduce its normal surgical load by half until on-site sterilization capability is restored, Dr. Tosi said.

Robert L. Moylan, the city director of public works and parks, said there is no ongoing problem with sediment contamination in city water. Any particles stirred up into the water flow after the Chandler Street water main break in November would have been flushed out in a day or two, he said.

Mr. Moylan said he wasn't in a position to know why UMass Memorial was only discovering the particles in its water lines and other equipment now, two months after the water main break.

“Whatever happened, happened then and there,” Mr. Moylan said. “We haven't had any calls on this at all. This is news to us.”

UMass Memorial said it tested the water at the Memorial Campus before resuming operations in November.

The extent of the work needed to rebuild the Belmont Street hospital's sterilization system is clear in an e-mail sent Friday to the hospital's surgical staff from Dr. Margaret Hudlin, vice president for perioperative services.

Dr. Hudlin said in the message that crews from a plumbing vendor will work around the clock through the weekend to begin the process of restoring sterilization capacity at Memorial Campus.

“All of the incoming water lines that lead to and that are located at various stages of the sterilization process are being fitted with new filters. These filters will prevent any particles that may be in the domestic water supply from entering the sterilizing equipment,” Dr. Hudlin wrote.

She said the hospital had hired a company to provide a team of plumbers and contractors available to work around the clock to replace water lines and filters. A sterilization vendor also will be brought in to help oversee replacement of equipment, including two main sterilizers that will be replaced on Monday, she said.

The work needed to bring the hospital back to a full surgical schedule could take between 10 days and three weeks, depending on the availability of necessary vendors, Dr. Hudlin wrote.

The hospital distributed a list of “talking points” to surgeons and nurse managers to help them explain the sudden surgical cancellations and postponements to patients.

The document advises staff to tell patients: “I realize this is very inconvenient for you, and I am sorry for the disruption this causes you. But we want to take every precaution necessary before we resume our surgical schedule.”